Received: 2 August 2018 | Accepted: 26 December 2018

DOI: 10.1002/ajim.22947

RESEARCH ARTICLE

Factors influencing health and safety practices

among Vietnamese nail salon technicians and owners:
A qualitative study

Tran B. Huynh PhD, CIH1 | Ngoc Doan BS2 | Ngan Trinh BS3 |
Niko Verdecias DrPH(c), MPH4 | Samantha Stalford BS5 | Amy Caroll-Scott PhD4

1 Department of Environmental and

Occupational Health, Dornsife School of
Public Health, Drexel University, Philadelphia,
Pennsylvania
2 Collegeof Engineering, Drexel University,
Philadelphia, Pennsylvania
3 Collegeof Science and Technology, Temple
University, Philadelphia, Pennsylvania
4 Community Health and Prevention, Dornsife
School of Public Health, Drexel University,
Philadelphia, Pennsylvania
5 Health Management and Policy, Dornsife
School of Public Health, Drexel University,
Philadelphia, Pennsylvania
Correspondence
Tran B. Huynh, PhD, CIH, Dornsife School of
Public Health, Nesbitt Hall, 3215 Market
Street, Suite 613, Philadelphia 19104, PA.
Email: tbh38@drexel.edu
Funding information
National Institute for Occupational Safety and
Health, Grant number: K01 OH011191-01;
Drexel Urban Health Collaborative Pilot Grant
Objective: This qualitative study explored factors that influence health and safety
practices among Vietnamese nail salon technicians and owners.
Methods: We conducted semi-structured focus group discussions and individual
interviews with a sample of 17 Vietnamese nail salon technicians and owners in the
Philadelphia metropolitan area, Pennsylvania.
Results: Analysis of transcripts revealed perceived health benefits/concerns,
knowledge about work-related hazards, salon's management and policies attributed
to owners, client influence, external policies/regulations, and protective equipment-
specific challenges were among factors affecting workplace health promotion
practices at the salons.
Conclusions: The study highlighted a complex interplay among the various stake-
holders including nail technicians, owners, clients, policy makers, and enforcers.
Interventions addressing barriers at the personal and organizational levels, as well as
public policy change and enforcement are needed to create sustainable behavioral and
organizational change in nail salons.
KEYWORDS
health disparities, multilevel interventions, nail salon workers, occupational health

1 | INTRODUCTION
The nail salon industry has experienced rapid growth within the last
20 years, seeing an increase of over 300% in the number of both nail
salons and technicians.1 Nationally, the population of licensed
technicians has grown to over 430 000, and remains predominately
comprised of females of reproductive age.2 The average annual wage
for a salon worker is estimated at $24 3303 and many tend to work
long hours and are responsible for over half of their household's
income.2 Many nail technicians also do not have basic health care
coverage.4 Over half of nail salon workers identify as Vietnamese in
Institution at which the work was performed: Dornsife School of Public Health.
the United States (US),2 a significant increase from only 10% in
1987.5,6 Vietnamese immigrants have been able to occupy a major
portion of the industry workforce because of limited training
requirements, the ability to work without English fluency, and
gaps in legislation and regulation.4,5,7 Many nail salon employees,
facing economic pressures to continue working, end up compromis-
ing their overall health.8
Nail salon workers encounter multiple hazards at the salons
including chemicals, ergonomic hazards, and potential infectious
diseases transmission from clients. Workers are exposed to hazardous
chemicals, such as toluene, formaldehyde, and dibutyl phthalate1,7,9–14
that are abundantly found in nail products. The long-term effects of
these chemicals have been associated with risk of reproductive and
cognitive development harm, cancer, allergies, and irritation to the

244 | © 2019 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/ajim Am J Ind Med. 2019;62:244–252.

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HUYNH ET AL.
| 245

respiratory, dermatological, and central nervous systems in other 2 | METHO DS

7,11,14–20
settings. While chronic adverse health effects such as
pregnancy complications, poor birth outcomes or cancers among 2.1 | Participant recruitment and study procedures
21,22
nail salon workers remain uncertain, acute health symptoms such
We recruited Vietnamese nail salon technicians and owners in the
as dermal and respiratory irritations and musculoskeletal pains, have
Philadelphia metropolitan area using a snowball sampling approach,
been consistently reported in several studies.7,11,14 In the literature,
due to the fact that this is a hard-to-reach and vulnerable population.33
most studies of salons focus on exposure assessment of chemicals
We initially tried cold calling without success and quickly learned from
such as toluene, ethyl acetate, isopropyl acetate, methyl methacry-
other nail technicians that referrals from former/current co-workers,
late,12,23 indoor air quality,12,24,25 and health outcomes.11,14,21,22
friends, and relatives was needed to reach this population. Part-time
Qualitative studies that explore facilitators and barriers to adoption of
and full-time nail technicians and owners (including former nail
occupational health best practices in immigrant-owned nail salons are
technicians) between the ages of 18 and 65 years were recruited to
lacking. To our knowledge, there is only one qualitative study
join the study between September 2016 and April 2017.
conducted in California with Vietnamese nail salon workers and
We sent a detailed informed consent document in either English or
owners that identified the role of key stakeholders, such as workers,
Vietnamese (whichever language was indicated as preferred) in
owners, consumers, and governmental regulators, in promoting
advance to participants who were willing to provide their contact
worker health.26
information to us. Not all participants provided their contact
Philadelphia, Pennsylvania is home to approximately 16 682
information to the research team in advance. Some preferred to
Vietnamese-Americans, which is the 9th largest Vietnamese
meet the team at a specified location. Prior to the start of each
population among US cities.27 There are about 396 salons in
interview/focus group, we orally went through the consent form,
Philadelphia county, of which close to half are owned by
provided participants with information regarding the purpose of the
Vietnamese owners.28 The Pennsylvania State Board of Cosmetol-
study, procedure of the interview/focus group, permission to audio
ogy regulates the practice and licensure of nail technicians, nail
record, plan to protect anonymity and confidentiality, and voluntary
salons, teachers of nail technicians, and training schools and
participation. Each interview and focus group lasted approximately 30-
apprentice programs.28 Requirements to become a licensed nail
45 min. Participants were offered a $20 gift card as compensation for
technician is minimal, which include a minimum educational level
their time. We provided participants a copy of the consent form to
equivalent to 10th grade, 200 h of training at a licensed
keep at the end of the session. The research protocol was reviewed
cosmetology school and an exam. The Board also prescribes
and approved by the Institutional Review Board at Drexel University.
management of nail salons including physical space and health and
Verbal informed consent was sought for each participant; signed
safety practices such as sanitation and sterilization of equipment,29
written informed consent was waived because it would be the only
largely designed to protect the customers not workers. Nail salons
record that linked participants to the study.
in Philadelphia must meet building codes in accordance with the
International Building Code,30 which in this case would require a
source capture system (also known as local exhaust ventilation
2.2 | Data collection
[LEV]) at each table.31 However, many salons in Philadelphia do not
have these systems. The Philadelphia Department of Public Health In this formative study, we employed both focus group discussion and
Environmental Health Services Division may also inspect and fine one-on-one interview methods in order to accommodate participants’
salons for sanitation violations. The Air Management Services schedules and preference. We organized two focus group discussions
regulates local and federal air quality standards for the city but it with nail technicians. We met one group of young female technicians
32
does not regulate air quality in nail salons. Fragmented local (N = 7, ages between 18 and 24 years old) at an Asian tea shop they
regulations and the lack of safe nail products regulations at the selected. The other focus group (N = 4, ages between 25 and 53 years
federal level4 lead to potentially unsafe exposures to chemicals and old) occurred at the private home of a technician who helped us recruit
other hazards to nail salon workers. To our knowledge, there are no other technicians. Based on participant preference, we also conducted
health promotion programs to assist nail salons workers in the one-on-one interviews with four nail technicians and two female
Philadelphia metropolitan area. owners. Owners/managers typically preferred to be interviewed at their
This qualitative study is part of a larger needs assessment project. salons, whereas technicians preferred to meet outside of their salons so
The purpose of the qualitative component of the assessment is to they would feel more comfortable expressing their opinions. Regardless
identify personal and environmental factors that influence health of the salons they worked at, we separated the owner/manager group
protective work practices among Vietnamese nail salon technicians from the technicians to avoid owner's influence on the technician's
and owners in the Philadelphia metropolitan area. Results from this responses. The interviews and focus groups were conducted in the
study, along with findings from a literature review and insights from a participants’ preferred language. Six were conducted in Vietnamese,
community advisory board, will be used to develop a multilevel two were in English. We created two semi-structured interview guides
occupational health intervention program for nail salon workers and (one for salon owners/managers and one for technicians) which were
owners. used for both the focus groups and one-on-one interviews.34 Though
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246 | HUYNH ET AL.

some questions were worded slightly differently for owners and TABLE 1 Demographics of Vietnamese Participants in the Study
workers, the open-ended questions from both interview guides covered (N = 17)
the same topics. We started out asking “warm-up” questions about: (i) Characteristic N %
how they entered the nail profession; (ii) health symptoms they Salon position
experience, and then moved on to substantive questions probing Owner/Managera 2 12%
around; (iii) knowledge of workplace hazards; (iv) current preventive Technician 15 88%
practices relating to chemical protection and ergonomics; and (v)
Estimated salons representedb 8
attitudes and barriers about certain occupational health best practices
Gender
(eg, use of personal protective equipment or ventilation system). After
Female 15 88%
each session, participants were also asked to complete a short
anonymous demographic survey. Male 2 12%

The Principal Investigator (PI) conducted all of the interviews and Marital Status
focus group discussions. The research assistants (ND and NT) took Married 7 41%
notes throughout each session to note interview or focus group Single 10 59%
dynamics and engaged in informal unrecorded talks with participants Age in years (Mean/SD) 33 (12)
(such as how and why they came to the US, their family, their career
Birthplace
aspirations) before and after each meeting so they would feel
Vietnam 15 88%
comfortable talking with us. After the first focus group, questions
US 2 12%
were modified and additional ones were included to further explore
Years in US (Mean/SD) 15 (11)
themes that emerged from the first discussion. The interviews were
audiorecorded, transcribed in Vietnamese, and translated to English by Years doing nail (Mean/SD) 7 (5.5)

bilingual and bicultural research assistants and reviewed by the PI for Hours worked/week (Mean/SD) 48.5 (16)
completeness of the translation. Education
Some high school 1 6%

2.3 | Analytic methods High school 6 35%

Some college 7 41%
Data consisted of eight transcripts that were uploaded into and coded
College 3 17%
using Atlas.ti version 8 (Cleverbridge AG, Cologne, Germany). The
Language spoken at home
coding team included the PI, part-time nail technicians who were also
undergraduate student research assistants (ND, NT), and graduate Vietnamese 10 59%

research assistants who were not knowledgeable about the industry English 1 6%

(SS, NV). The coding process began with multiple coders performing
open coding on two transcripts using a grounded theory approach.35
The team met to discuss and resolve differences between coders and
the initial list of codes. Next, focused codes were created and
discussed that were relevant to the research questions. Once a coding
scheme was finalized through an iterative process of coding, team
discussion and consensus-building, all the transcripts were coded using
the final scheme by multiple coders. Additional codes were added to
the coding scheme as they arose and were later reviewed for group
consensus. After the coding was completed, emerging themes were
identified. Illustrative quotes were extracted to substantiate the
findings derived from the themes and codes. Pseudonyms were used
to protect the privacy of participants. The inclusion of multiple coders
with diverse perspectives throughout the process helped the team
maintain objectivity and avoid biased interpretation of the data.
2.4 | Participant characteristics
Seventeen adults participated in the study, including 15 females (88%)
and two male technicians (12%) (Table 1). They represented eight salons
from different neighborhoods in both central Philadelphia and
surrounding suburbs. We were able to visit only three of these salons
Both 6 35%
a
There was one participant whose managerial status was confirmed with us
through her co-worker but she preferred to consider herself to be a
technician. Most Vietnamese managers and owners also work as
technicians.
b
Number of salons represented was estimated because there were three
participants whom we were not able to confirm where they worked.
(one located inside a large mall and two on relatively busy streets) where
we interviewed two female owners and a female technician who
appeared to have some managerial role in the salon. The majority of
participants were technicians (88%), born in Vietnam (88%), and
primarily speak Vietnamese at home (59%). On average, study
participants were 33 years old (range = 18-53 years). The mean number
of years living in the US was 15 years, ranging from being born in the US
to having been in the US for 33 years. The reported time being in the nail
profession ranged from 1 to 17 years and the majority of participants
reported working more than 40 h per week. Study participants had a
variety of educational backgrounds obtained in either Vietnam or the
US. Three (17%) were college graduates. One manager was a US college
graduate who took over the ownership of her mother's salon so that her
mom could work less and the other used to work part-time while
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HUYNH ET AL.
| 247

attending school. We had no background information on the third TABLE 2 Summary of Major Themes
college graduate. Seven participants had some college education (41%) Adverse health symptoms mentioned
which included a couple of college dropouts who ended up working full- Respiratory irritation
time at the salons and the rest were full-time students at a community
Eyes irritation
college or university working part-time during the school year and full-
Headaches
time in the summer. Other full-time nail technicians were older or
Dry crack skin, eczema
recently came to the US with limited English skills. Almost all got into the
Musculoskeletal pain (shoulder, back, hands)
profession through connections with family or friends. We did not ask
about their nail licenses as such sensitive question might affect their Protective practices

engagement during the discussion. Chemical protection

Turning on general ventilation system
Using personal protective equipment such as gloves, surgical masks
3 | RE SULTS
Keeping salon clean

Analysis of the transcripts revealed three major themes relating to our Opening doors to ventilate the space
core research question: (i) health symptoms experienced; (ii) protective Proper handling of chemicals (e.g., label containers, store chemicals
practices; and (iii) factors that influence the adoption of health and soaked cotton balls in a small container, take out trash at the end of
the day)
safety best practices in the nail salons. We identified sub-themes
related to the third theme and explored how they could serve as Musculoskeletal prevention

motivators or barriers to performing protective actions by the nail Siting up straight

technicians and owners/managers (Table 2). Similarities and differ- Not using too much force on the hands
ences between the groups in their perspectives were also reported. Doing exercises such as walking and yoga
Standing up to walk between customers
Taking pain relievers
3.1 | Health symptoms experienced Getting help from family members
Most participants reported having experienced adverse health Using a raised platform to support hands
symptoms that they thought could be related to chemicals in nail Factors influencing health and safety practices
products such as acetone, glue, liquid used in acrylic nails (methyl Perceived health benefits/concerns
methacrylate or MMA), and gel nails. These symptoms included
Knowledge about health and safety at work
sneezing, eczema, eye irritations, dry/cracked and itchy skin on the
Salon's management and policies attributed to owners
hands, and headaches. For instance, one female technician mentioned
Client influence
her issue with gel nails:
External regulations/policies

“When I do gels, my eyes feel sticky and itchy. . . When I Protective equipment-specific challenges

don’t do gel, I don’t have those symptoms. I do not have

those issues with acrylic nails, only with gel nails. My eyes
feel like there is a pus in my eyes. It's slightly sticky. I’m just We found that the owners/managers reported either less or no
not comfortable working with gel.” (Female nail negative health symptoms or concerns compared to the nail
technician). technicians:

One older male technician, however, thought some of these
symptoms could be related to pollens or allergens outside of work. It
should be noted that this male technician consistently dominated the
group discussion and refuted health concerns brought up by other
participants. Our informant later told us that he was a manager but he
had indicated to us that he was a technician.
In addition to chemical concerns, musculoskeletal symptoms such
as shoulder and back pain were also mentioned, “I have shoulder and
back pain,” said one female technician from the group discussion.
Another female nail technician mentioned hearing about nail workers
needing surgery on their fingers, “There are people who have to have
surgery on their fingers because they hold customers’ hands for too
long. . . Some people lost sensation on their finger.”
“I have done nails for a long time but have not seen any
effect. No regular illness... I’m not sure about new workers
but I myself have worked for a long time and I feel fine. Just
normal. (Female owner)”
3.2 | Protective practices
3.2.1 | Chemical protection
All participants indicated that they adopted some forms of protective
practices when working at the salons. These practices included the use
of ventilation (eg, fans, general mechanical ventilation or keeping the

248 | HUYNH
door open), wearing personal protective equipment, proper storage
and handling of chemicals (eg, transferring bulk chemicals into smaller
containers with labels, storing chemicals soaked cotton balls in a small
container and discarding them at the end of the day), having indoor
plants, and keeping the salon clean.
The use of gloves and surgical masks were mentioned more often
than other practices. These practices appeared to vary between study
participants, the type of nail services being performed, and salons. All
participants reported using surgical masks for dust and chemical
protection. All but one young male technician were unaware of the N-
95 respirator for dust protection. The male technician talked about his
preference for the N-95 respirator but it was unclear whether it was
accessible to him. All participants reported using gloves and they used
gloves for pedicures more often than manicures. One female
participant described her typical gloves use:
“It's normal when doing pedicure, just uncomfortable
when doing manicure.” (Female nail technician)
3.2.2 | Musculoskeletal prevention
Regarding musculoskeletal prevention, more experienced workers
appeared to know how to better protect themselves than less experienced
ones. Some participants reported not doing anything about the muscular
pain they experienced. Others recounted examples of measures that they
took, which included being aware of the posture, sitting up straight, not
putting too much force on the hands, working out or doing yoga after
work, standing up to walk between clients, taking pain relievers, or having
family members help at the shop so that they can work less. One female
owner thought that handling hands constantly could cause shoulder pain
and shared how she took care of herself, “You have to be aware of your
posture when you are sitting instead of hunching over. You have to sit up
straight. Most people want to get close to customer's nails so that you can
see the details. A lot of people have bad posture.” In addition, she and her
sister also worked at the salon so their mom can work less, “My sister and I
are here helping her so she can work less.”
Another seasoned female owner shared that she used a raised
platform to rest her hands so that she did not have to use too much
force holding the client's hands:
“I always have this cushion to support my hands when I
work. There are many people who do not know. Just pull
their hand up and lift. I put my hand on this cushion. No
need to lift or hold people's hands up. Then I have the right
angle to work.” (Female owner)
When asked about doing body stretches during free time at work, one
young female participant in a focus group said that she would not do it
because she did not think her owner would support it and even if they did,
she might consider doing very light exercises, “ I would just do something
light that does not require too much force. We’re in a salon. Doing
stretches like you’re dancing would make you look like a crazy person.”
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ET AL.
Overall, the owners/managers tended to report better adherence
to safety practices in their salons compared to the nail technicians.
3.3 | Factors influencing adoption of health and
safety practices
3.3.1 | Perceived health benefits/concerns
Most participants mentioned self-protection as one of the reasons
they performed safe work practices. This attitude is shared by both the
nail technician and the owner/manager groups.
“Because there are many nails disease that you may not
know. When someone who has a disease gets cut, you can
get infected. So the gloves are a must-have.” (Female nail
technician)
3.3.2 | Knowledge about health and safety at work
The level of health and safety knowledge appeared to vary among
participants and topics. Many participants mentioned that they knew
working with chemicals can affect their health:
“[Acrylic] has liquid, then when we file, there are dusts
from the powder. You will inhale those dusts, it is not
good.” (Female nail technician)
Some had no knowledge of the potential risks of chemicals:
“I do not know if it actually affects our health.” (Female nail
technician)
“I don’t really know if there is anything we have to really be
worried about health risk. Like anything in life that you are
doing, there is always risk of cancer. I don’t think I have
seen it here or I have heard of it.” (Female owner)
Knowledge appeared to be gained and/or reinforced by the health
effects that they or people they know experienced at work:
“At that time I did not know, but after working for a while, I
realized it.” (Female nail technician)
Similarly, personal experience seems to shape the participant's
perceived susceptibility and severity of the potential health effects
more than knowledge. A female owner recalls her pregnancies:
“I was nervous at first. Because I heard that women who
work in the nail industry during pregnancy, may have some
effects on their children later on. I also asked the doctor. The
doctor also advised me to wear protective masks and other
things. . . We should also pay attention to any little thing at

HUYNH ET AL.
the time of pregnancy. When I have three children, all three
children are healthy. There are many people in my family
who do not do nails but their kids are not healthy. I think it
may just depend on each of our body types.” (Female owner)
Participants have basic knowledge of ways to protect their health
from chemical and infectious diseases transmission such as use of
gloves and masks. Many participants did not know about local exhaust
ventilation. When shown pictures of individual mobile local exhaust
machine, none of the participants said their salons had such machines
or similar units. People generally know about the general ventilation
but not the local exhaust ventilation.
We found having the knowledge does not necessarily translate to
consistent practices due to barriers discussed below.
3.3.3 | Salon's management and policies attributed to
owners
Results showed support from owners was related to technicians’
health and safety behaviors. Many Vietnamese salons are family-
owned and owners typically hire Vietnamese technicians. The work
environment is often perceived like family:
“Everybody looks out for everybody in the salon, you know.
It is very much we are in a close group.” (Female owner)
However, not all technicians felt that way. Management styles and
organizational policy varied between owners and salons. Some owners
treat employees better than others and also encourage using
protective equipment.
While owners/managers could be a source of motivation, they can
also be barriers. One former nail technician revealed that when she
used to work at a family owned salon, she sensed that the owner was
not happy with her using some of the personal protective equipment
so she did not use them even though they were available at the salon.
Another technician told us that “Some owners just don’t care.” She
knew of one owner who did not want her technicians to wear gloves
because she feared that wearing gloves might leave a bad impression
on the customers:
“I actually know the lady that own the nail salon that did
not want people to wear gloves, cause she [the owner]
took different way, thinking when you wear gloves, you
grossed out the clients, and she did not want the client to
feel like what's wrong with my feet. There were times that
she said you guys should stop wearing gloves.” (Female nail
technician)
Instead of providing gloves to workers, some owners/managers
may suggest that the technicians buy gloves themselves:
“Only worker will support it [wearing gloves] because
owner does not want to provide it. But sometimes the boss
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| 249
is also nice enough to suggest buying gloves ourselves.”
(Female nail technician)
3.3.4 | Client influence
Customers can play a big role in influencing nail salon's practices in a
positive way which can reinforce the technician's and owner's
protective practices:
“In the beginning, when you first introduce to that concept,
I think they [clients] were taken back. . . But after a while,
they understand it. I mean you are working with the
chemical, it's dirty stuff. They started to understand more.
It is actually protecting the clients and also the workers.”
(Female nail technician)
There is, however, variability in customers’ perceptions and preferences
toward certain salon health and safety practices that could make it difficult
for the workers to adhere to good practices. For instance, if clients were
allergic to latex, technicians were requested not to wear gloves:
“There are also people who are allergic to latex gloves that
they let you know. So I do not wear gloves at their request.”
(Female owner)
Or when the salon's door is kept open to facilitate air circulation,
clients might express their dislike of noise or insects:
“But many times the customers do not like the door to be
opened. Sometimes the flies can come in or the noise of
traffic is annoying.” (Female nail technician)
Client preference affected both the owner/manager and nail
technician groups.
3.3.5 | External regulations/policies
Owners had the responsibility to be compliant with the laws and thus
were more responsive to legal/contractual requirements and law
enforcers compared to the nail technicians:
“When opening the shop [in the mall], they required me to
install a ventilation system. . . Here this [general] ventila-
tion costs thousands of dollars.” (Female owner)
3.3.6 | Protective equipment-specific challenges
While many nail technicians supported the use of protective
equipment (masks and gloves), they also expressed challenges in
using them. These included discomfort, blurriness in their glasses
(masks use), slipperiness, and slowing them down (gloves use).

250 | HUYNH
When asked about potential challenges of having or using a local
exhaust ventilation unit, participants talked about the potential noise,
entanglement, too busy to turn it on, or that the owner might not want to
install it because of the cost:
“I do not think the owner would like that because it costs
[money] to install and fixes it if something big breaks. Or if
you have too many customers coming in you do not have
time to turn it on.” (Female nail technician)
4 | DISCUSSION
The purpose of the study was to identify factors that influence the
adoption of safe practices among Vietnamese nail salon technicians
and owners in the Philadelphia metropolitan area. Our findings
revealed a complex interaction between personal and environmental
factors that affect health and safety practices in nail salons.
Nail salon workers talked about several acute health symptoms
related to chemical use, ergonomics, and infectious disease hazards
that they or their co-workers experienced such as headaches,
respiratory, eye, and skin irritation, and pain in the shoulders, back,
and hands. However, they were less certain about more serious health
risks such as pregnancy-related outcomes or cancers. Acute symptoms
reported by our participants were consistent with the literature from
several quantitative cross-sectional health surveys of nail salon
technicians in different states, including California and Massachu-
setts.7,11,14 The owners and managers were more likely to be
dismissive of the health risks than the nail technicians in their
responses.
Cognitive behavioral factors such as knowledge, perceived
health risks and benefits were influencing factors among both the
nail technicians and owners and managers. We learned that even
though some workers and owners may report knowing about
potential health hazards, their perceived susceptibility and
severity of more serious adverse health conditions were generally
low. This may be due to the perceived lack of evidence of the
longer-term health risks associated with working at nail salons that
they or people in their network encountered. The statistics of
severe chronic health conditions associated with the nail profes-
sion is also limited in the literature, which might be due to the
difficulty in conducting research in this hard-to-reach population
and healthy worker effects where seriously-ill workers tend to
leave their jobs.
While some basic knowledge about the hazards and control
measures were generally known among the participants, misconcep-
tions about certain health and safety practices also existed. These
included, but were not limited to, the use of surgical masks for dust and
chemical protection or the belief that muscular pains is mostly due to
aging. Some of these misunderstandings were consistent with reports
7
of nail salon practices from other states, which might indicate that
information/training gaps persist not only in Philadelphia but
potentially among the larger nail salon industry's niche involving nail
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ET AL.
salon workers and owners. One potential reason for the continued use
of these surgical masks was that they were much less expensive, more
comfortable to wear, and friendlier looking than the recommended
N-95 respirators. While outreach programs targeting existing techni-
cians and owners will address short-term training gaps, more
sustainable efforts might need to involve changing curriculum in
cosmetology schools, apprentice programs, and nail salon regulations.
Our qualitative analysis also found several important workplace
environmental factors that played significant roles in shaping nail salon
safety practices. First, different owners have different management
styles and organizational policy within their salons that can affect
technicians’ behaviors. Educating owners and managers of health and
safety best practices may help owners establish better organizational
policy and reinforce health promoting behaviors for workers. Second,
clients can also either positively or negatively influence a salon's
practices. Thus, it would be interesting to compare salon practices by
neighborhoods (eg, customers from affluent neighborhood may be
more willing to pay for higher prices for safer and more expensive
products). Lastly, owners and technicians are generally responsive to
external requirements and law enforcement. Many family-owned
salons operate on low profit margins so strict regulations such as
installing local exhaust ventilation might negatively impact small
businesses due to potential high cost of implementing and maintaining
the system. Therefore, consideration of a balanced regulatory
approach (eg, providing economic assistance to small businesses)
might attract more owner's buy-ins and bring more sustainable change
in this industry.
The results of our study may be impacted by several limitations. One
limitation is the small sample of nail technicians and owners that may not
be representative of the experiences of all Vietnamese nail salon
workers in Philadelphia. Although our sample size is relatively small, we
found repeated themes in most of the transcripts which indicated to us
that some level of thematic saturation was reached. Another limitation is
the limited inference to other ethnic groups that make up the rest of the
nail industry's workforce including English-speaking Non-Hispanic
Whites and African Americans, other Asian ethnic groups and Latino/
Hispanic minorities. We recommend future research to explore the
experiences and organizational culture of workers from those racial/
ethnic groups in order to better understand industry-wide best practices
and optimize outreach efforts. However, it is possible that some of what
we found among Vietnamese workers, most of whom were immigrants,
could be applicable to salon workers who emigrated to the US from
other countries. It is also possible that our results may be unique
geographically because other municipalities and states may have
different requirements for nail salon operations and thus would impact
their safety practices. For instance, New York has now implemented
ventilation regulation for nail salons requiring a source capture system at
each nail table36 but some cities in California use a voluntary approach
where salons are incentivized to be legally recognized as being a healthy
nail salon.37 There is also a possibility of social desirability bias and
misclassification of the participants’ roles in the salons, particularly
among the owners and managers. There were two participants who self-
reported to be nail technicians but we later learned through our
 10970274, 2019, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ajim.22947 by Rmit University Library, Wiley Online Library on [21/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HUYNH ET AL.
| 251

informant that they were managers. Managers of small nail salons often AUTHORS’ CONTRIBUTIONS
also work as technicians and thus would sometimes prefer to classify
TBH conceptualized the study, led the collection, analysis, and
themselves as technicians. While we took their actual status into
interpretation of the data, and manuscript preparation. TBH is
account in our transcript analysis, this status misclassification may pose
responsible for all aspects of the work. NG and NT assisted in the
challenges in future study where we may not have informants to confirm
data acquisition and analysis. SS and NV were involved in the data
their backgrounds and thus identify any potential bias in their response.
analysis. All authors (including AC) contributed to the interpretation of
There were differences that arose from combining individual
the data and editing of the manuscript.
interviews and focus group discussions into one analysis. Responses
from individual interviews tend to be more in-depth than focus groups,
ACKNOWLEDGMENTS
as the interviewer could probe and clarify responses. On the other
hand, moderators of the focus group discussions had to navigate We wish to thank all the participants in the study.
dynamics between dominant and shy participants. Yet these
discussions took advantage of the dynamic nature of a focus group FUNDING
discussion, including the stimulation of richer responses and the ability
to build consensus. We felt that having both methods allowed us to Grant sponsor: US Center for Disease Control and Prevention,

balance the breath and depths of the topics. It also allowed us to National Institute for Occupational Safety and Health (NIOSH); Grant

engage nail technicians who would not have agreed to participate number: K01 OH011191-01; Grant sponsor: Drexel Urban Health

without being able to do so with their trusted peers. Thus allowing Collaborative Pilot Grant.

participants to self-select into focus group discussion or interview

helped to increase our response rate in this formative study. Lastly, ETHICS APPROVAL AND INFORMED CONSENT
much of the information was obtained via focus groups rather than
This study was approved by the Institutional Review Board at Drexel
individual-level surveys, thus precluding us from learning the
University's Office of Human Research Protection. All participants
frequency with which certain views are shared within this sample.
provided oral informed consent.
That said, the knowledge gained from conducting these focus groups
will inform the development of a survey instrument that could assess
prevalence and frequency of experiences in future phases of the study. DISCLOSURE (AUTHORS)
Despite these limitations, a major strength of this study was the
The authors declare no conflicts of interest.
use of qualitative methods to gain a more in-depth understanding of
the complex interplay between the personal and environmental factors
that contributed to the current occupational health practices of DISCLOSURE B Y AJIM EDITOR OF RECORD
Vietnamese nail salon technicians and owners. These formative
Steven B. Markowitz declares that he has no conflict of interest in the
findings provide a foundation upon which to expand the research
review and publication decision regarding this article.
such as interviews with policy makers, cosmetology school educators,
and customers. They will also inform the development of a healthy nail
salon intervention program and help us identify opportunities for DISCLAIMER
outreach and policy changes for more sustainable prevention efforts
None.
for this worker population.

5 | C ONC LU SI ON S
Our study highlighted a complex interplay between personal and
environmental factors that influence health and safety practices
among Vietnamese nail technicians and owners. Our results
confirm the need to incorporate linguistic and cultural components
in future intervention programs but also highlight barriers to
healthier salons and worker behaviors that must be addressed at
multiple levels as much as possible. This will require key stake-
holders such as technicians, owners, cosmetology educators,
researchers, public health professionals, community organizations,
the public, and policy makers working in synergy to create more
sustainable behavioral and system changes for the health and well-
being of workers in the nail industry.
ORCID
Tran B. Huynh http://orcid.org/0000-0002-1542-8582
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How to cite this article: Huynh TB, Doan N, Trinh N,
Verdecias N, Stalford S, Caroll-Scott A. Factors influencing
health and safety practices among Vietnamese nail salon
technicians and owners: A qualitative study. Am J Ind Med.
2019;62:244–252. https://doi.org/10.1002/ajim.22947